In this first decade of the new century, the healthcare industry has undergone accelerated changes regarding cost and quality. We have known since the advent of Diagnosis Related Groups (DRGs) that longer lengths of stay do not necessarily equate to increased reimbursement. Longer lengths of stay (LOS) actually reduce profits and result in a dependence on increased volume to make up the deficit. Clearly linked to costs are quality outcomes. Poor quality care results in increased rates of complications and a resultant increased LOS. Examples of complications that can cause increased LOS are pressure ulcers, deep vein thrombosis and infections.

Payers expect hospitals to provide safe quality care in a fiscally sound environment. At a time when hospitals face enormous financial pressures, the industry is being challenged to accept full accountability related to hospital-acquired infections. Healthcare reimbursement and nosocomial infections are now "best friends forever" or more affectionately known as BFFs in both for-profit and not-for-profit hospital environments.

From a cost perspective, corporate advocacy groups such as Leap Frog and Health Grades have formed in an attempt to be a voice of corporate business. Their goals are to reduce escalating costs in healthcare. Similarly, critical care groups such as The American Association of Critical-Care Nurses (AACN) and The Society of Critical Care Medicine (SCCM) are speaking of "evidence based practice". The goals are to improve quality by initiating changes in nursing and medical practice at the bedside.

Critical care nurses are trained to provide complex care in the safest environment possible. Ironically, we also know that patients in ICUs are at an increased risk for hospital acquired infections. Because critical care patients are more likely to develop infection, a focus on prevention versus treatment becomes paramount. In this issue, ten articles reveal differing perspectives of infection and infection prevention in the critical care environment.

History would say it takes a "village" to produce a great product. Our village is a team of healthcare providers working collaboratively to attain collective goals. Our intended product is a patient who is infection free and healthier than when he or she first presented to us. Unfortunately, the number of Healthcare-Associated Infections (HAI) has been estimated to be well over 1.7 million (CDC, 2007) with associated costs of treatment ranging from 35 to 45 billion dollars. By instituting infection control interventions, a large number of HAIs can be prevented. The benefits of prevention have been estimated to range from 6.8 billion (20% prevented) up to 31.5 billion (70% prevented).

In the past, our 'village' was often comprised of separate townships. Silos of care created fragmented treatment resulting in poor communication and gaps in treatment. In the least, there can be care delivery delay, and at worst, these gaps can result in sentinel events. The Centers for Disease Control (CDC) and The Healthcare Infection Control Practices Advisory Committee (HICPAC) recognize the impact that fragmented care has on the incidence of HAIs. Fundamental to an effective HAI prevention plan is the understanding that participation must occur collaboratively, in all-organizational aspects, in our village.

To be effective, the prevention of HAIs must have broader ownership than that of the individual, including a transformation to an institutional and environmental culture of responsibility.

This issue of CCNQ, with a focus on HAI, has compiled a diverse group of healthcare professionals with differing perspectives. Topics range from environmental considerations such as designing a new ICU and effective cleaning to prevent infections and a worst-case scenario of a pandemic. Readers are invited to consider visitation restrictions in the ICU; is it about protecting the patient or something else? Timely questions are asked such as: how does evidence help us make informed decisions related to infection control practice? What are the common quality reviews performed by hospitals? What is the best evidence concerning ventilated patients and the potential for developing pneumonia? Finally, the authors want to share a real life struggle and lessons learned combating a bug called Legionella in two of the five Baptist hospitals.

Critically ill patients are dependent upon the healthcare system to provide an environment of healing. The need for hospitals to be highly reliable providers of safe patient care is an ever-evolving obligation to the public. Therefore, the reader will experience how the relationships between those who understand infections and those who provide patient care have combined their profession skills to reach this goal. Our commitment to those in need enables us to share this issue of Critical Care Nurse Quarterly.

Laura Miller, MSN, RN

Issue Co-Editor

Chief Nursing Officer

Baptist Medical Center

San Antonio, Texas